If you have a true medical emergency, always go directly to the nearest emergency room or call 911 for help. In other cases, you’re welcome to use the
Contact Us form to send us an inquiry online and we’ll respond the next business day. You can also access personalized information about your PacificSource coverage online 24/7 through InTouch for Members.
Register or
log in now.

Federal law requires all insurers to obtain and report Social Security numbers of their insured members to the Centers for Medicare and Medicaid Services (CMS). Please be assured that we have sufficient security procedures in place to protect against inappropriate release of that information.

If you’re covered under a group health plan, your employer is the policyholder. Contact your employer to request a copy of the insurance policy or a Member Benefit Handbook.

If you’re covered under a PacificSource individual and family plan, you received the policy when you enrolled or changed plans. You can request a replacement copy from our Individual Sales Department: phone (888) 684-5585 or e-mail
individual@pacificsource.com.

Your summary of benefits is available online in InTouch for Members, our secure member Web site.
Register or
log in now. If you’re covered under a group health plan, you’ll find a copy in your Member Benefit Handbook, or you can request one from your employer. The Summary of Benefits is included in your policy document if you have a PacificSource individual and family plan.

You can order a new member ID card any time by logging into InTouch for Members, our secure member Web site.
Register or
log in now. You’re also welcome to use the
Contact Us form to request a new card, or call our Customer Service staff at (888) 977-9299 during business hours.

This is most often due to custody arrangements. For dependent children, the insurance ID card is issued only to the custodial parent. This is true even if the noncustodial parent is the primary policyholder. The child’s name will not appear on a noncustodial parent’s ID card. If this circumstance doesn’t apply to you and you believe there’s an error on your ID card, please contact our Customer Service staff at (888) 977-9299.

You can update your contact information any time by logging into InTouch for Members, our secure member Web site.
Register or
log in now. You’re also welcome to use the
Contact Us form any time, or call our Customer Service staff at (888) 977-9299 during business hours.

Several of our Customer Service team members are fluent in Spanish. For Spanish language assistance, you may call (541) 684-5456 or (800) 624-6052, ext. 5456. We can also provide Spanish translations of all our Member Benefit Summaries and most forms and materials upon request.

Preauthorization

Preauthorization is prospective review of a proposed healthcare treatment to determine availability of insurance benefits, medical necessity, and appropriateness. Sometimes it also includes assessment of the level of care and treatment setting.

Certain medical services and prescription drugs require preauthorization in order to be considered for coverage under your plan. In those cases, your provider is to obtain preauthorization from PacificSource before the treatment is provided. Failure to preauthorize when required may result in you being held responsible for payment to your provider if the services aren’t covered by your plan.

Preauthorization is a service for you and your healthcare provider that helps:

You’ll find an up-to-date listing of the types of
services that require preauthorization on our Web site. If your procedure isn’t specifically listed but might fall under one of the broad categories on our preauthorization list—such as experimental or investigational procedures—it will require further inquiry. PacificSource Customer Service can verify whether a procedure requires preauthorization if we have your procedure’s billing code. Ask your provider to call us to check on preauthorization.

Outpatient mental health and chemical dependency services do not require preauthorization; you may self-refer to eligible providers. For our members with significant care needs, we conduct concurrent review and may request a treatment plan from the treating provider for case management purposes.

When considering preauthorization requests, we review all pertinent information available and we may communicate with your healthcare provider if additional clinical information is needed. Our preauthorization guidelines are based on current medical evidence, clinical criteria, and medical necessity and are reviewed and updated as needed.

Requests must be received in writing from the requesting physician or healthcare provider. The
preauthorization request form must be completed in full before we can begin the preuathorization process. We may require related chart notes and/or clinical information to make our best determination.

As soon as a preauthorization determination is made, we mail notice of the decision to the member, physician, and facility or vendor. You and your provider can also check the status of your preauthorization request by
logging into InTouch, or by calling our Health Services Department at (888) 691-8209.

To have your claim reconsidered for coverage, have your provider’s office submit a retrospective preauthorization request. The provider should include the fully completed
medical preauthorization request form along with related chart notes and/or operative report to support the request. We will process the request within 30 days of receipt.

Referrals

A referral is the process by which your primary care provider (PCP) directs you to other providers, usually specialists, for further care. Some health plans require you to get a formal referral from your PCP before you see a specialist or other type of provider. When appropriate, your PCP will request a referral from PacificSource on your behalf.

Plan Benefits and Coverage

UCR—or “usual, customary, and reasonable”—usually applies to services of nonparticipating or noncontracted providers. It’s the fee allowance we use to calculate benefits for dental providers and nonparticipating medical providers.

It depends on your specific policy. Under most plans, once you’ve met your out-of-pocket maximum, you’ll have no further out-of-pocket expenses for services of participating providers for the rest of the plan year. However, some plans have specific services that don’t apply to the out-of-pocket maximum, and/or services for which you continue to have a cost share even after your out-of-pocket maximum is met. Refer to your Summary of Benefits or contact PacificSource Customer Service at (888) 977-9299, or by e-mail at
cs@pacificsource.com for more information on your plan’s out-of-pocket maximum provisions.

When there’s an auto accident, your PacificSource policy’s “third party liability” provisions apply. In third party cases, the other coverage—in this case, auto insurance—has primary responsibility for paying your medical expenses up to that policy’s limits. Your PacificSource policy then takes over to cover any remaining medical expenses. Don’t worry, though—our Third Party Recovery Department will work with you to help ensure that your expenses are covered.
Learn more about how third party recovery works.

Coverage depends on your specific plan design. In general, testing supplies (strips and lancets) and blood glucose monitors are covered under the medical plan, while insulin, syringes, and needles are covered under prescription drug benefits. Insulin infusion pumps and supplies and needle-free systems require preauthorization to determine coverage. Diabetic education is a covered benefit, and we also have a free diabetic meter program for members. Contact our Customer Service staff at (888) 977-9299 for details of your coverage.

Specific mental health benefits vary and are determined by your insurance policy. Please refer to your benefit summary or Member Benefit Handbook – available through
InTouch for Members - or call our Customer Service staff at (888) 977-9299 for details of your coverage. Mental health care may include:

Our
Care Coordination Request form can help you communicate your healthcare needs as a new member transitioning to PacificSource. This form is especially helpful if you have ongoing healthcare needs, are involved in an active treatment plan, and would like to verify that your treatment will be covered. Services well suited to care coordination include maternity care, cancer care, treatment of trauma or acute conditions, or surgery or hospitalization scheduled within 90 days of your policy’s start date. After submitting your form, you will receive a follow-up phone call from a Health Services Representative. If appropriate, we’ll then assign a Nurse Case Manager to work with you during your transition to PacificSource.

Case management is a service available to all PacificSource members who have complex or chronic medical conditions and require support to manage their healthcare needs. It is a service aimed at improving health outcomes and quality of life and reducing healthcare costs.

Our case managers are registered nurses with extensive clinical experience. They work collaboratively with you and your healthcare providers to provide improved clinical, humanistic, and financial outcomes for you.

Case management can be of great help to members experiencing a wide range of complex medical issues, such as:

Transplant

Chronic pain management

Extended hospital or skilled nursing care

Home medical services or equipment

Special needs children

If you think you might benefit from case management, you’re welcome to contact our Health Services Department at (888) 691-8209.

No, we cannot offer à la carte benefits. Health insurance is a highly regulated industry. All health plan designs and premium rates must be filed and approved by the state insurance departments where we do business. In addition, many benefits are mandated by law—meaning federal or state regulations require insurers to cover them.

Probably not. Immunizations for the purpose of travel are generally excluded from health plan coverage. However, a handful of employer group policies have exceptions to this rule because their employees are frequently required to travel to other parts of the world. You’re welcome to contact PacificSource Customer Service at (888) 977-9299, or by e-mail at
cs@pacificsource.com if you think your employer may have made an exception allowing this coverage.

Note: As part of healthcare reform, deductibles and coinsurance will be waived for participating providers as policyholders renew on or after September 23, 2010 (grandfathered plans excluded). Please check with your employer to see if this applies to your plan.

How are flu vaccines covered under my pharmacy benefits?

If your plan has a pharmacy benefit, you can obtain a flu vaccine shot from our participating flu shot pharmacy network. (Mist and high-dose shots are not covered under the pharmacy benefit.) Simply show your PacificSource member ID card at one of our participating flu shot clinics to receive a flu shot at no cost! PacificSource will be billed directly, with no paperwork, deductibles, or copayments required.

An emergency medical condition is an injury or sudden illness, including severe pain, so severe that a prudent layperson with an average knowledge of health and medicine would expect that failure to receive immediate medical attention would risk seriously damaging the health of a person (or fetus, in the case of a pregnant woman). Examples of emergency medical conditions include (but are not limited to):

Medically necessary means those services and supplies that are required for diagnosis or treatment of illness or injury and that in the judgment of PacificSource are:

Consistent with the symptoms or diagnosis and treatment of the condition;

Consistent with generally accepted standards of good medical practice in the state of Oregon, or expert consensus physician opinion published in peer-reviewed medical literature, or the results of clinical outcome trials published in peer-reviewed medical literature;

As likely to produce a significant positive outcome as, and no more likely to produce a negative outcome than, any other service or supply, both as to the disease or injury involved and the patient’s overall health condition;

Not for the convenience of the member or a provider of services or supplies;

The least costly of the alternative services or supplies that can be safely provided. When specifically applied to a hospital inpatient, it further means that the services or supplies cannot be safely provided in other than a hospital inpatient setting without adversely affecting the patient’s condition or the quality of medical care rendered.

Each employer’s group policy has specific eligibility rules for dependent children. Under most group policies, dependent children who are full-time students can remain covered until they reach age 23 or are no longer a full-time student, whichever occurs first. Each employer’s eligibility rules can vary, so check with your employer or see your Member Benefit Handbook for details about your policy’s dependent eligibility criteria.

Your insurance contract with PacificSource includes two eligibility qualifications for employee coverage: the minimum number of hours worked, and the employee probationary period. Those eligibility qualifications are set by the employer, and the employer must treat all employees of the same employment class equally. If an employee has been employed for the number of days required by your probationary period, and is working the minimum hours required by your plan, then you are obligated to offer coverage under your group plan.

You can remove members from your plan online using InTouch for Plan Administrators portal.
Register or
log in now. You can also contact your Membership Service Representative in writing (via fax, mail, or e-mail) to request that we remove members from your plan. We’re unable to accept member termination requests by phone as we need written documentation for our records.

It depends how much time has elapsed since the original eligibility date.

If the original eligibility date was within the current month or the prior month, we can retroactively enroll the employee back to that original eligibility date.

If the original eligibility date was prior to last month, the policy’s late enrollee provisions will apply. The employee will be subject to a six-month wait—beginning the first day of the month after we receive the enrollment application—before coverage can begin.

Dependents can be added to the employee’s coverage at the time of a “qualifying event” defined in the policy. Those events include involuntary loss of other coverage, return to school (for group plans that have a full-time student requirement), marriage, birth, or adoption. For dependents seeking enrollment without a qualifying event, the policy’s late enrollee provisions apply. The dependent is be subject to a six-month wait—beginning the first day of the month after we receive the enrollment application—before coverage can begin.

No, we must ask that you pay as billed rather than making adjustments to your statement. We will adjust your premium for the enrollment change on your next monthly statement. Paying as billed helps both you and us reconcile your monthly premium.

While your group policy premium is due on the first day of the coverage month, members on continuation coverage have until the last day of that month to pay their premium. If you’ve not received a former employee’s premium by the time you make your monthly premium payment, you have two options:

Keep the former employee on your plan by including their premium in your monthly payment to us. You can then attempt to collect the premium, and terminate their coverage retroactively if premium is still not paid by the end of the month. To terminate the coverage retroactively, submit your request in writing to your PacificSource Membership Service Representative. We will then make the premium adjustment on your next month’s billing, provided no claims have been reimbursed for that month.

Terminate the former employee’s coverage back to the last day of the last month for which premium was received. If the employee then submits the current month’s premium to you by the last day of that month, you’ll need to reinstate their coverage. To do so, contact your Membership Service Representative to request the member’s reinstatement and fax us receipt of their premium payment. We will then make the premium adjustment on your next month’s billing.

If your policy terminated for nonpayment, it’s because we did not receive and post your payment before the end of the month for which it was due. If we have not received and posted your payment to our system during the coverage month, the policy will automatically terminate on the last day of that month. The termination will be retroactive to the last day of the last month for which premium was received.

Group policy premium is always due on the first day of the coverage month. Premium payments are received at a secure lockbox—not at our offices—so we are unable to rely on a postmark to determine whether your payment was timely.

Check your PacificSource Member ID card for your plan name. You’ll find it just below the PacificSource logo. You'll also find your plan name in the Medical Plan Info section of InTouch for Members. Register or log in now.

Yes, although you’ll receive your plan’s highest level of benefits when you use participating providers. Unless it’s a medical emergency, your benefits are lower when you seek treatment from a nonparticipating provider. See your plan’s Summary of Benefits (available in InTouch for Members—register or log in now), or contact our Customer Service staff at (888) 977-9299 or
cs@pacificsource.com for specific information on your coverage for nonparticipating providers.

This is a rare occurrence, but should it happen, we’ll ensure that you have appropriate continuity of care. We’ll provide you with written notice that the provider’s contract will be terminating. We will allow for you to continue treatment by that provider under your plan's participating provider benefit level for a period of time after the contract terminates. Our Health Services team will also help you transition your care to a new participating provider when appropriate. If you choose to continue seeing the provider, your plan's nonparticipating provider benefit level will then apply.

Network Not Available (NNA) means a member does not have reasonable geographic access, as determined by PacificSource, to a contracted participating provider for a medical service or supply. In these cases, we may make certain exceptions to a plan’s participating/nonparticipating benefits. Contact Customer Service at (888) 977-9299, or by e-mail at
cs@pacificsource.com if you think this may apply to your situation.

There are many types of qualified mental health professionals, and individual practitioners often specialize in certain types of patients or cases. A good first step is to ask your primary care doctor to recommend a mental health professional with the qualifications and experience to treat your condition. Then use our online
Provider Directory to confirm that the provider participates in the PacificSource network. You’ll receive your plan’s highest level of benefits if you use participating providers.

The providers listed below are those trained in different areas of mental health care:

Psychiatrist: A licensed medical doctor who specializes in the diagnosis, treatment, and prevention of mental illnesses. They may work with you on problems like depression, or more complex issues like schizophrenia. Psychiatrists can prescribe medications.

Psychologist: A licensed specialist who provides clinical therapy or counseling for a variety of mental health care conditions. They have earned a doctorate degree in psychology and are required to complete several years of supervised practice before becoming licensed.

Counselor/Therapist: A specialist who provides mental health services to diagnose and treat mental and emotional health issues. They may use a variety of therapeutic techniques. Licensed Counselors have a master’s or doctoral degree in counseling or a related area.

Neuropsychologist: A licensed psychologist with expertise in how behavior and motor skills are related to brain structures and systems.

Social Worker: A specialist who provides treatment for social and health problems. Some social workers may work in employee assistance programs or as case managers who coordinate psychiatric, medical, and other services on your behalf. Others specialize in domestic violence or chronic illness. Most social workers have a master’s degree in social work; many are licensed as a LCSW.

Psychiatric Nurse: Licensed registered nurses (R.N.) who have extra training in mental health. Under supervision of medical doctors, they may offer mental health assessments and psychotherapy and they may help manage medications. Advanced practice registered nurses (A.P.R.N.) can diagnose and treat mental illnesses.

Marriage and Family Therapist (MFT): Therapists who evaluate and treat disorders within the context of the family. These therapists provide help with a range of problems, such as depression, parent-child conflicts, and eating disorders.

Grievances and Appeals

PacificSource honors and upholds the right of every member to express concern about their coverage and quality of care, to receive information about our services and providers, to participate in decision-making regarding their healthcare, and above all, to be treated with respect and recognition of their dignity and right to privacy.

We understand that inevitably, questions or feedback regarding coverage may arise. We pledge to address your concerns thoroughly and fairly, and to resolve them as quickly as possible. In medically urgent situations, we will expedite the review process to ensure that decisions are made in a timely manner so our members receive the care they need.

Concern means any expression—written or verbal—of dissatisfaction with PacificSource.

Inquiry means a written request for information or clarification about any matter related to a member’s health plan. An inquiry is not a complaint or grievance.

Complaint means an expression of dissatisfaction about a specific problem encountered by a member, treatment by a provider, or decision made by PacificSource. A complaint must include a request for action to resolve the problem or change the decision. Grievances and appeals fall under this category.

For concerns, inquiries, and complaints, we follow an informal review process, especially if the issue can be resolved fairly easily. If a member’s complaint is identified as either a grievance or an appeal (typically when it’s formally written that way), we follow what’s called a formal review to determine how it can be resolved. The form your communication takes—written or verbal—has a strong effect on how it’s handled by us.

An informal review is the process by which we respond to verbal concerns or complaints and all inquiries. Every effort is made to resolve issues at this level, and informal review matters are often resolved within a single phone call. These issues are frequently related to day-to-day matters, such as verification of benefits or eligibility, interpretation of the insurance contract, clarifications of billing statements or EOB statements, and case management matters.

A formal review is how we usually respond to grievances and appeals. This level of review requires us to follow a four-part system to appropriately investigate, resolve, document, and report grievances and appeals. Once we establish that a formal review is necessary, the grievance or appeal is forwarded to a Grievance Coordinator, who is responsible for coordinating a review of the matter and keeping the member informed about our decision.

Complaints about healthcare coverage or quality of care fall into one of two categories:

A grievance is a written complaint submitted by a member (or on the member’s behalf) about the quality of services PacificSource offers. This can include issues such as the availability, delivery, or quality of healthcare services; utilization review decisions; or claims payment, handling, or reimbursement for services. You should file a grievance if you believe that medically necessary care that is covered by your health plan has been denied, reduced, or ended unduly and you want to receive care.

An appeal is a written request submitted by a member (or on the member’s behalf) requesting reconsideration of a previous decision we made in the grievance and appeals process.

Before submitting a grievance, we suggest you contact our Customer Service Department with your concerns. Issues can often be resolved at this level. You can reach us by phone at (888) 977-9299, or by email at
cs@pacificsource.com.

Otherwise, you may file a grievance or appeal (see our Appeal Form PDF):

That depends on the degree of the issue. Your grievance or appeal will be forwarded to a Grievance Coordinator, and within seven days we’ll send you an acknowledgement that the complaint has been received. Then, you’ll receive notice of a decision on your matter within 30 days of filing the complaint. If your complaint requires longer than 30 days, we’ll send you a notice explaining the reason for the delay, and you should receive a final decision no more than 45 days after filing your complaint. If your situation is urgent, the Grievance Coordinator will work with you to ensure that your grievance or appeal is resolved as quickly as possible.

Along with notice of our decision, we will provide you with information on how to file an appeal at the next level.

Under certain circumstances, you may have the right to have your case reviewed by an external independent review organization to dispute our decision on your appeal. If we denied benefits because we determined that services were not medically necessary or were experimental or investigational, you have this right. In addition, if you believe you have a right to continue treatment with a provider who is no longer eligible for payment by us, your appeal may be reviewed externally. Your request for an independent review must be made within 180 days after you receive our final decision. External independent review is available at no cost to you, but is only an option for issues of medical necessity, experimental or investigational treatment, and continuity of care after all internal grievance levels are exhausted.

Benefit summaries are specific to each member. Once you're logged into InTouch for Employers, perform a member search to pull up the specific member's record, and you can then access that member’s plan summaries.

If our system already contains separate mailing and home addresses for a subscriber, then you can change the mailing address online without also changing the home address. Otherwise, any update you make to the home address will automatically update the mailing address (even though it won't appear that you’ve made that change). To add a separate mailing address after the subscriber is enrolled, please contact your PacificSource Membership Representative.

Type the employee’s zip code in the “Zip” field and then click the “Look-up” button. A window will appear listing all towns within that zip code. Click the zip code link next to the correct entry and the city, county, and state fields will auto-populate.

Verify that you are using a valid subgroup and class rather than one that would not be current at the time of the employee’s date of hire or effective date. (InTouch currently assumes a default class of 1001, so be sure to change this if that is not the subscriber's correct class.)

If the effective date of the correct class comes after the member's hire date (regardless of the member's effective date), the class will not be available for you to enroll online. In such cases, please send the subscriber's application to your Membership Representative for manual entry.

If both of the above have been ruled out, please contact the InTouch for Administrators Team for assistance at (541) 225-3742 or
intouch4admins@pacificsource.com. Please provide as many details as you can: most important are your group number, the subscriber's name, the subgroup and class you are using, and a description of the error.

Please contact the InTouch for Administrators Team for assistance at (541) 225-3742 or
intouch4admins@pacificsource.com. Please provide as many details as you can: most important are your group number, the subscriber's name, the subgroup and class you are using, and a description of the error.

Other Coverage information and Prior Coverage information does not currently translate directly into our database. If you have these details during a new enrollment or reinstatement, please contact your Membership Representative or the InTouch for Administrators Team after processing the online enrollment.

Please contact our InTouch for Administrators team for assistance at (541) 225-3742 or
intouch4admins@pacificsource.com. Please provide as many details as you can: most important are your group number, the subscriber's name, the subgroup and class you are using, and a description of the error.

Check that you are entering the same member number and password that you used when you originally registered. If you have a newly-issued member ID card, the number may be slightly different than the one you originally used to register.

If you haven’t logged in for more than two years, your registration may have been automatically disabled as a security precaution.

Contact our Customer Service staff. You can reach us by phone at (888) 977-9299 during business hours, or by e-mail at
cs@pacificsource.com. Or, use the
Contact Us form to get help with your question. Be sure to include as much detail as possible: your member ID number, a description of what you're trying to do, and notes about any error message. Please provide either a daytime phone number where we can call you, or a valid e-mail address, so we can follow up promptly.

InTouch for Agents

You might be following an outdated link or bookmark to the login page. Try logging in by going directly to the
Login page. You can also click on the InTouch Login link located on the upper right hand side of the screen on any page.

You can reach the InTouch for Agents team by phone at (800) 624-6052 during business hours, or by e-mail at
intouchforagents@pacificsource.com. Or, use the
Contact Us form to get help with your question. Please provide as many details as you can: your Producer number, the name of the group you are quoting, a detailed description of the problem you are encountering, any error message you are receiving, and screen shots if possible.

InTouch for Providers

You might be following an outdated link or bookmark to the login page. Try logging in by going directly to the
Login page. You can also click on the InTouch Login link located on the upper right hand side of the screen on any page.

You are welcome to contact our Provider Network Department at (541) 684-5580 or toll-free at (800) 624-6052, ext. 2580. Or contact your
Provider Service Representative directly. Please provide as many details as you can: your NPI, a detailed description of the problem you are encountering, any error message you are receiving, and screen shots if possible.